Nokea
A patient's chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?
- A. Decreased HR
- B. Paresthesias
- C. Muscle weakness of the extremities
- D. Migraines
Correct Answer: D
Rationale: The correct answer is 'Migraines.' Migraines are not a symptom typically associated with hyperkalemia. In acute hyperkalemia, one would not expect to see migraines. Symptoms of hyperkalemia often include muscle weakness, paresthesias, and cardiac manifestations such as bradycardia or even cardiac arrest. Therefore, choices A, B, and C are more commonly associated with acute hyperkalemia compared to migraines, making it the correct choice.
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A healthcare professional is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
- A. S. pneumoniae
- B. H. influenzae
- C. N. meningitidis
- D. Cl. difficile
Correct Answer: D
Rationale: The correct answer is Cl. difficile. Clostridium difficile (C. diff) is not typically associated with meningitis in humans. This bacterium is known to cause severe diarrhea, usually as a result of antibiotic treatment. S. pneumoniae, H. influenzae, and N. meningitidis are all known to be causative agents of meningitis in humans. S. pneumoniae is a common cause of bacterial meningitis, especially in adults. H. influenzae, particularly type b (Hib), used to be a leading cause of meningitis in children before the introduction of the Hib vaccine. N. meningitidis is another significant pathogen responsible for causing meningitis, especially in young adults and adolescents.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
- A. Place a call to the client's healthcare provider for instructions
- B. Send him to the emergency room for evaluation
- C. Reassure the client's wife that the symptoms are transient
- D. Instruct the client's wife to call the doctor if his symptoms become worse
Correct Answer: B
Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.
A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms?
- A. Anesthesia reaction
- B. Hyperglycemia
- C. Hypoglycemia
- D. Diabetic ketoacidosis
Correct Answer: C
Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (Choice A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (Choice B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (Choice D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.
A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
- A. IgA
- B. IgD
- C. IgE
- D. IgG
Correct Answer: D
Rationale: IgG is the only immunoglobulin that can cross the placental barrier, providing passive immunity to the fetus. About 70-80% of the immunoglobulins in the blood are IgG. Specific IgG antibodies are generated after an initial exposure to an antigen, offering long-term protection against microorganisms. IgG antibodies are critical for protecting the fetus as they can be rapidly reproduced upon re-exposure to the same antigen. IgA is primarily found in mucosal areas, IgD is involved in antigen recognition, and IgE is associated with allergic reactions, but they do not provide the same level of protection to the fetus as IgG.
The client is seven (7) days post total hip replacement. Which statement by the client requires the nurse's immediate attention?
- A. I have bad muscle spasms in my lower leg of the affected extremity.
- B. I just can't 'catch my breath' over the past few minutes and I think I am in grave danger.
- C. I have to use the bedpan to pass my water at least every 1 to 2 hours.
- D. It seems that the pain medication is not working as well today.
Correct Answer: B
Rationale: While all statements by the client require attention, the most critical one that demands immediate action is option B. Clients who have undergone hip or knee surgery are at an increased risk of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are hallmark signs of this condition. Without appropriate prophylaxis such as anticoagulant therapy, deep vein thrombosis (DVT) can develop within 7 to 14 days after surgery, potentially leading to pulmonary embolism. It is crucial for the nurse to recognize signs of DVT, which include pain, tenderness, skin discoloration, swelling, or tightness in the affected leg. Signs of pulmonary embolism include sudden onset dyspnea, tachycardia, confusion, and pleuritic chest pain. Option B indicates a potentially life-threatening situation that requires immediate intervention to prevent serious complications.